Protocol Status: PUBLISHED
Protocol:
Version: 2026.01
Effective Date:
Last Reviewed:
Medical Director Approval:
Clinical Note: This content reflects current GCEMS clinical guidelines as of the dates listed above. If content appears inconsistent with current policy, use the most recent approved guideline and notify leadership for correction.

Pleural Decompression

 

 Clinical Indications:

 

  • To relieve tension pneumonthorax.
    • May occur in the setting of chest trauma, COPD, PPV, spontaneously
    • Consider among (H’s and T’s) in cardiac arrest. Particularly in the setting of penetrating traumatic arrest.

 

 Signs and symptoms include:

 

  • Clinical evidence of a pneumothorax

 

    • Absent or decreased unilateral breath sounds.
    • Other less sensitive signs include:
      • Asymmetrical chest movement with inspiration
      • Hyper-expanded chest on affected side
      • Drum like percussion on affected side
      • Increased resistance to positive pressure ventilation, especially if intubated

 

AND

 

    • Evidence of tension physiology

 

      • Hemodynamic instability: shock or rapidly decreasing blood pressure

 

 Procedure:

 

  • Elevate head of stretcher to 30 degrees.
  • Expose the entire chest.
  • Identify the second intercostal space midclavicular on the side of the pneumothorax.
    • Place finger on the clavicle at its midpoint.
    • Run this finger straight down the chest wall to locate the first palpable rib between the clavicle.
    • The second intercostal space lies just below this rib, midway between the clavicle and the nipple line.
  • Alternatively, identify the 4th or 5th intercostal space, anterior-axillary line. (Preferred location in patients with larger chest size)
    • Raise arm above and over head.
    • Identify the edge of the pectoralis muscle. (anterior axillary line)
    • The nipple line or inferior-most border of axillary hair typically represents the 4th intercostal space.
      • Consider that the nipple may be displaced inferiorly in female patients, may not correlate with the 4th ICS.
  • Cleanse the area with an alcohol or povidone-iodine swab.
  • Select a 10, 12, or 14 gauge (at least) 3" IV catheter (Pediatric: 16 gauge, 1 ¼ inch).
  • Advance the needle above the rib. (blood vessels and nerves run along the underside of the rib.)
  • As you enter the pleural space, you will feel a pop and note a rush of air expelling.
  • Advance the catheter into the chest and then withdraw the needle. Be careful not to kink the catheter.
  • Auscultate breath sounds.
  • Secure with gauze and tape.
  • Ventilate and monitor ETCO2.
  • If symptoms fail to improve, consider the site alternate to initial attempted (above), contact Online medical control for further guidance.

 

 Contraindications:

 

  • Hemodynamic and respiratory stability